Perfectionism, weight and shape concerns, and low self-esteem: Testing a model to predict bulimic symptoms Carmelo La Mela a , Marzio Maglietta a, ⁎, Saverio Caini a , Giuliano P. Casu b , Stefano Lucarelli a,b , Sara Mori a , Giovanni Maria Ruggiero c a Cognitive Psychotherapy Clinical Centre, Via delle Porte Nuove, 10, 50144, Florence, Italy b Dipartimento Salute Mentale, ASL 11 Empoli c “Studi Cognitivi”, Post-graduate Cognitive Psychotherapy School, Foro Buonaparte, 57, 20121, Milan, Italy abstract article info Article history: Received 23 December 2014 Received in revised form 2 July 2015 Accepted 16 September 2015 Available online xxxx Keywords: Bulimic symptoms Eating disorders Perfectionism Body dissatisfaction Self-esteem Previous studies have tested multivariate models of bulimia pathology development, documenting that a confluence of perfectionism, body dissatisfaction, and low self-esteem is predictive of disordered eating. However, attempts to replicate these results have yielded controversial findings. The objective of the present study was to test an interac- tive model of perfectionism, weight and shape concerns, and self-esteem in a sample of patients affected by Eating Disorder (ED). One-hundred-sixty-seven ED patients received the Structured Clinical Interview for DSM-IV Axis I (SCID-I), and they completed the Eating Disorder Examination Questionnaire (EDE-Q), the Rosenberg Self-Esteem Scale (RSES), and the Multidimensional Perfectionism Scale (MPS-F). Several mediation analysis models were fit to test whether causal effects of concern over weight and shape on the frequency of bulimic episodes were mediated by perfectionism and moderated by low levels of self-esteem. Contrary to our hypotheses, we found no evidence that the causal relationship investigated was mediated by any of the dimensions of perfectionism. As a secondary finding, the dimensions of perfectionism, perceived criticism and parental expectations, were significantly correlat- ed with the presence of bulimic symptoms. The validity of the interactive model remains controversial, and may be limited by an inadequate conceptualization of the perfectionism construct. © 2015 Elsevier Ltd. All rights reserved. 1. - Introduction Binge eating and purging are important symptoms of Eating Disor- ders (ED) (American Psychiatric Association, 2000; Byrne, Fursland, Allen, & Watson, 2011; Fairburn et al., 2009), and understanding the onset of these behaviors is critical (Fairburn, Marcus, & Wilson, 1993). The three-factor theory by Bardone-Cone and colleagues (Bardone, Vohs, Abramson, Heatherton, & Joiner, 2000; Vohs, Bardone, Joiner, Abramson, & Heatherton, 1999; Bardone-Cone et al., 2007) implicates an interaction between high perfectionism, low self-esteem, and high body dissatisfaction and provides a model of bulimic behavior. Since its formulation, Bardone-Cone's model has undergone empiri- cal investigation. The first empirical test predicted bulimic symptoms on a population of college students (Vohs et al., 1999). The model replicat- ed in one study (Vohs et al., 2001), but not in another (Steele, Corsini, & Wade, 2007). In a further adaptation (Bardone-Cone, Abramson, Vohs, Heatherton, & Joiner, 2006), self-esteem was interchanged for self- efficacy. The model predicted binge eating, but not purging. In a cross- sectional study (Tissot & Crowther, 2008), self-oriented and socially prescribed perfectionism dimensions were incorporated (Stice, 1994; Stice, 2001), but the model failed to replicate. Among female adoles- cents, the model was not supported (Shaw, Stice, & Springer, 2004), and among females with a mean age of 45 years, the model predicted maintenance of bulimic symptoms, but not onset (Holm-Denoma et al., 2005). The first study on a clinical sample (Bardone-Cone et al., 2008) confirmed the three-way model among women with Bulimia Nervosa (BN). A second study (Watson, Steele, Bergin, Fursland, & Wade, 2011), on a population of ED outpatients, found that the three- way interaction did not predict binge eating or purging. Considering these mixed results, this study was designed to provide an independent replication of an interactive model of perfectionism, weight and shape concerns, and self-esteem predicting binge episodes in a sample of ED patients. 2. - Methods 2.1. Study participants The present study used a cross-sectional perspective. Participants were consecutive patients with ED referred from February 2012 to Eating Behaviors 19 (2015) 155–158 ⁎ Corresponding author at: Cognitive Psychotherapy Clinical Centre, Via Delle Porte Nuove, 10, 50144, Florence, Italy. E-mail addresses: carmelo.lamela@scuolacognitivafirenze.it (C. La Mela), marzioma@katamail.com (M. Maglietta), saverio.caini@gmail.com (S. Caini), giuliano.casu@usl11.toscana.it (G.P. Casu), stefanolucarelli@hotmail.com (S. Lucarelli), morisara1981@gmail.com (S. Mori), gm.ruggiero@studicognitivi.net (G.M. Ruggiero). http://dx.doi.org/10.1016/j.eatbeh.2015.09.002 1471-0153/© 2015 Elsevier Ltd. All rights reserved. Contents lists available at ScienceDirect Eating Behaviors